\t\t\t<\/p>\n
\tJulie Rovner
\n\tKFF Health News<\/p>\n
\t\t\t \t\t\t \t\t\t \t\t\tJulie Rovner is chief Washington correspondent and host of KFF Health News\u2019 weekly health policy news podcast, \u201cWhat the Health?\u201d A noted expert on health policy issues, Julie is the author of the critically praised reference book \u201cHealth Care Politics and Policy A to Z,\u201d now in its third edition.\t\t<\/p>\n Millions of people in Republican-dominated states are among those seeing their Affordable Care Act plan premiums spike for 2026 as enhanced, pandemic-era subsidies expire. Yet Republicans in the White House and on Capitol Hill are firming up their opposition to extending those additional payments \u2014 at least for now.<\/p>\n Meanwhile, Democrats may not have achieved their shutdown goal of renewing the subsidies, but they have returned health care \u2014 one of their top issues with voters \u2014 to the national agenda.<\/p>\n This week\u2019s panelists are Julie Rovner of KFF Health News, Paige Winfield Cunningham of The Washington Post, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.<\/p>\n \t\t\t \tPaige Winfield Cunningham \t\t\t \t\t\t \t\t\t \tJoanne Kenen \t\t\t \t\t\t \t\t\t \t\t\t \tShefali Luthra \t\t\t \t\t\t Among the takeaways from this week\u2019s episode:<\/p>\n Also this week, Rovner interviews Avik Roy, a GOP health policy adviser and co-founder and chair of the Foundation for Research on Equal Opportunity.<\/p>\n Plus, for \u201cextra credit\u201d the panelists suggest health policy stories they read this week that they think you should read, too:\u00a0<\/p>\n Julie Rovner:<\/strong> CNBC\u2019s \u201cCheaper Medicines, Free Beach Trips: U.S. Health Plans Tap Prescriptions That Feds Say Are Illegal<\/a>,\u201d by Scott Zamost, Paige Tortorelli, and Melissa Lee.\u00a0\u00a0<\/p>\n Paige Winfield Cunningham: <\/strong>The Wall Street Journal\u2019s \u201cMedicaid Insurers Promise Lots of Doctors. Good Luck Seeing One<\/a>,\u201d by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty.\u00a0\u00a0<\/p>\n Joanne Kenen:<\/strong> ProPublica\u2019s \u201cWhat the U.S. Government Is Dismissing That Could Seed a Bird Flu Pandemic<\/a>,\u201d by Nat Lash.\u00a0\u00a0<\/p>\n Shefali Luthra: <\/strong>ProPublica\u2019s \u201c\u2018Ticking Time Bomb\u2019: A Pregnant Mother Kept Getting Sicker. She Died After She Couldn\u2019t Get an Abortion in Texas<\/a>,\u201d by Kavitha Surana and Lizzie Presser.\u00a0\u00a0<\/p>\n Also mentioned in this week\u2019s podcast:<\/p>\n \t\t\t\t\tClick to open the transcript\t\t\t\t<\/p>\n \t\t\t\t\t\tTranscript: The GOP Circles the Wagons on ACA<\/strong>\t\t\t\t<\/p>\n [<\/em>Editor\u2019s note:<\/em><\/strong>\u00a0This transcript was generated using both transcription software and a human\u2019s light touch. It has been edited for style and clarity.]<\/em>\u00a0<\/p>\n Julie Rovner:<\/strong>\u00a0Hello from KFF Health News and WAMU Public Radio in Washington,\u00a0D.C., and welcome to\u00a0\u201cWhat the Health?\u201d\u00a0I\u2019m\u00a0Julie Rovner,\u00a0chief Washington\u00a0correspondent for KFF Health News, and\u00a0I\u2019m\u00a0joined by some of the best and smartest health reporters in Washington.\u00a0We\u2019re\u00a0taping this week on Thursday, Nov.\u00a020,\u00a0at 10\u00a0a.m. As always, news happens fast,\u00a0and things might have changed by the time you hear this. So,\u00a0here we go.\u00a0<\/p>\n Today,\u00a0we are joined via video conference by Paige Winfield Cunningham of\u00a0The Washington Post.\u00a0<\/p>\n Paige Winfield Cunningham:<\/strong>\u00a0Hi,\u00a0Julie.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Shefali Luthra of\u00a0The\u00a019th.\u00a0<\/p>\n Shefali Luthra:<\/strong>\u00a0Hello.\u00a0<\/p>\n Rovner:<\/strong>\u00a0And\u00a0Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.\u00a0<\/p>\n Joanne Kenen:<\/strong>\u00a0Hi,\u00a0everybody.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Later in this episode,\u00a0we\u2019ll\u00a0have my interview with Avik Roy, longtime Republican\u00a0health\u00a0care\u00a0adviser\u00a0and\u00a0chair of the Foundation for\u00a0Research on\u00a0Equal\u00a0Opportunity.\u00a0But first,\u00a0this week\u2019s news.\u00a0<\/p>\n So,\u00a0Democrats may not have\u00a0\u201cwon the shutdown,\u201d\u00a0but they\u00a0definitely got\u00a0health reform back on the national agenda. The last time we had such a full-scale health debate was in 2017, which\u00a0didn\u2019t\u00a0end particularly well for Republicans. For a while,\u00a0it looked like there might be enough Republicans who were worried about\u00a0\u2014\u00a0oh, I\u00a0don\u2019t\u00a0know\u00a0\u2014\u00a0their voters seeing their ACA\u00a0[Affordable Care Act]\u00a0insurance made effectively unaffordable that there might be a compromise in the offing.\u00a0But now it seems that\u00a0ship\u00a0has\u00a0sailed,\u00a0and the two sides have retreated to their respective corners. That\u00a0certainly seemed to be\u00a0the case at the Senate Finance Committee hearing on Wednesday,\u00a0where Republicans and Democrats\u00a0basically talked\u00a0past each other for three hours. Am I missing something? Is there some glimmer of hope here that\u00a0I\u2019m\u00a0not seeing that when they have this vote in a couple of weeks, the Republicans are all going to say,\u00a0Yeah,\u00a0let\u2019s\u00a0extend those subsidies?<\/em>\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0It\u2019s\u00a0funny, Julie, I was thinking, was it last weekend,\u00a0I think,\u00a0that Trump tweeted about we need to bypass the insurers and send the money directly to consumers? And for a couple of days,\u00a0there was all this buzz around\u00a0Is this going to be yet another chance for Republicans to do something big on health\u00a0care?<\/em>\u00a0And the whole time I was thinking:\u00a0Was anybody around in 2017? This\u00a0isn\u2019t\u00a0going to go\u00a0anywhere.<\/em>\u00a0And especially,\u00a0you could sort of predict this just because calls to redirect the subsidies\u00a0\u2014\u00a0which are a core part of the ACA\u00a0\u2014\u00a0away from the marketplaces, also a core part of the ACA\u00a0\u2014\u00a0directly\u00a0into tax-free savings accounts\u00a0obviously\u00a0[were]\u00a0always going to be a no-go with Democrats.\u00a0So\u00a0the idea that this was\u00a0kind of what\u00a0Republicans were talking about, this\u00a0isn\u2019t\u00a0even in the realm of possibilities that could be a bipartisan agreement on health\u00a0care.\u00a0<\/p>\n There seems for a little while to be a semi-earnest effort in the Senate to come up with some kind of bipartisan plan.\u00a0I know I spoke with folks for Sen.\u00a0[Jeanne]\u00a0Shaheen\u00a0[D-N.H.]\u00a0earlier this week who say\u00a0they\u2019ve\u00a0been talking to 10 to 12 Republican offices who say\u00a0they\u2019re\u00a0interested in some kind of deal and extending the subsidies.\u00a0But honestly, when you start stacking up\u00a0all of\u00a0the barriers that would be in the way of getting a deal, one of them is abortion funding.\u00a0I mean, this seems\u00a0\u2014\u00a0<\/p>\n Rovner:<\/strong>\u00a0We\u2019ll\u00a0get to that later.\u00a0Don\u2019t\u00a0jump the gun on that.\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0But\u00a0that\u2019s\u00a0a huge one. And then also,\u00a0just the inability,\u00a0and just how far apart the parties\u00a0are on\u00a0talking about health\u00a0care affordability and how you manage to bring down costs for people.\u00a0It\u2019s just\u00a0really hard\u00a0to see this going anywhere.\u00a0So,\u00a0my prediction is that we see Republicans\u00a0kind of coalesce\u00a0around their own thing. Democrats coalesce around their own thing.\u00a0And ultimately,\u00a0we\u00a0don\u2019t\u00a0see an extension of the subsidies.\u00a0<\/p>\n Rovner:<\/strong>\u00a0What happens in January,\u00a0though,\u00a0when people\u00a0actually start\u00a0coming to town hall meetings and saying:\u00a0Hey, we had to give up our health insurance because it was going up $4,000 a month?<\/em>\u00a0Might this build when these cuts\u00a0actually occur\u00a0in January?\u00a0<\/p>\n Kenen:<\/strong>\u00a0The Republicans have floated health savings accounts for\u00a0actually a\u00a0couple of decades now.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Since the 1990s.\u00a0<\/p>\n Kenen:<\/strong>\u00a0Right, that\u2019s decades.\u00a0<\/p>\n Rovner:<\/strong>\u00a0The first pilot project was in HIPAA\u00a0[Health Insurance Portability and Accountability Act]\u00a0<\/strong>in 1996.\u00a0<\/p>\n Kenen:<\/strong>\u00a0And it is not what people want. I mean, it is what some people want in conjunction with\u00a0an\u00a0HSA alone. There are plans that are a combination of\u00a0\u2014\u00a0in the exchange it would be a\u00a0\u201cbronze\u201d\u00a0\u2014\u00a0but this is not what the American people have.\u00a0\u2026 They have not been saying:\u00a0Please,\u00a0take away my health\u00a0care,\u00a0and give me a couple of thousand\u00a0bucks\u00a0instead.\u00a0<\/em>That\u2019s\u00a0not what\u00a0we\u2019re\u00a0hearing,\u00a0or my health\u00a0insurance,\u00a0I should\u00a0say,\u00a0and\u00a0take away.\u00a0<\/p>\n Rovner:<\/strong>\u00a0That\u2019s\u00a0the point. Also,\u00a0I\u2019m\u00a0seeing all these Republicans now saying we should not be giving money to the big, rich, bloated insurance companies,\u00a0who we do know are unpopular instead\u00a0\u2014\u00a0<\/p>\n Kenen:<\/strong>\u00a0Except for Medicare Advantage.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Thank you for finishing my\u00a0sentence. So,\u00a0finish my\u00a0sentence\u00a0for me, Joanne.\u00a0<\/p>\n Kenen:<\/strong>\u00a0Medicare Advantage, which has bipartisan support now\u00a0\u2014\u00a0not without some qualifications and criticism\u00a0\u2014\u00a0Medicare Advantage is here. Many Democrats use it,\u00a0and many\u00a0Democratic lawmakers support it. But Medicare Advantage is private insurers who are being paid more than government-traditional Medicare to pay for people\u2019s health\u00a0care.\u00a0So\u00a0it is not a coherent,\u00a0well-thought-out ideologically,\u00a0or technically,\u00a0or politically savvy plan that is going to solve the Republicans\u2019\u00a0problems on Jan.\u00a01, Jan.\u00a02, Jan.\u00a03, and you name the date after that.\u00a0People who got subsidies for health\u00a0care insurance are going to lose them, and many of them are\u00a0[President Donald]\u00a0Trump voters. And\u00a0that\u2019s\u00a0a reality, period.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Paige, I know you\u2019ve been looking into this\u00a0pretty closely.\u00a0Is there anything new here? I mean, it does seem that giving people money to go out and bargain on their own has been the Republican mantra,\u00a0I know,\u00a0since the 1990s.\u00a0They\u2019ve\u00a0had\u00a0all this time. Where is the plan?\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0Let\u2019s\u00a0just think about the numbers here on HSA. So,\u00a0I think the average subsidy\u00a0[that]\u00a0the average marketplace consumer gets is around $6,500. OK,\u00a0that\u2019s\u00a0fine\u00a0\u2014 great\u00a0\u2014\u00a0if\u00a0you\u2019re\u00a0healthy. If you\u2019re sick\u00a0\u2014\u00a0if you have diabetes,\u00a0or you have cancer\u00a0\u2014\u00a0say you have $6,500 in your account, [and] you don\u2019t have health\u00a0insurance,\u00a0that\u2019s not going to come anywhere close to the cost that you need to cover your cost of care.\u00a0So\u00a0this whole conversation\u00a0isn\u2019t\u00a0about\u00a0the healthy\u00a0people, right? The conversation is about the sick people who\u00a0bring up\u00a0the costs, who need\u00a0the insurance, who\u00a0can\u2019t\u00a0afford the care. And HSAs and FSAs\u00a0[flexible spending\u00a0accounts]\u00a0\u2014\u00a0especially HSAs,\u00a0though\u00a0\u2014\u00a0I\u00a0think\u00a0are\u00a0largely used\u00a0by wealthier people, healthier people, and it is a way to\u00a0maybe put\u00a0a\u00a0couple\u00a0extra hundred\u00a0bucks\u00a0in your pocket to pay for health\u00a0care. It is not a sweeping long-term solution to making sure that people can afford the cost of care.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Right.\u00a0It\u2019s\u00a0a great way\u00a0to pay for your eyeglasses and your dental care,\u00a0maybe,\u00a0if\u00a0you\u00a0don\u2019t\u00a0need a lot of dental care.\u00a0<\/p>\n Kenen:<\/strong>\u00a0It\u2019s\u00a0not just sick people.\u00a0It\u2019s\u00a0also\u00a0pregnancy.\u00a0It\u2019s\u00a0also people who are healthy until they get sick. You\u00a0can\u00a0\u2014\u00a0<\/p>\n Rovner:<\/strong>\u00a0I keep saying this:\u00a0I fell and broke my wrist,\u00a0and it cost $30,000. $6,500 would not have begun to put a dent in it. Sorry, Shefali. You wanted to say something?\u00a0<\/p>\n Luthra:<\/strong>\u00a0No, I was just going to\u00a0say to\u00a0Joanne\u2019s point about pregnancy\u00a0and\u00a0your point about breaking bones: Some of the people who are most vulnerable in this kind of situation\u00a0[are]\u00a0families.\u00a0Maybe you\u00a0give birth, something the administration really talks about supporting.\u00a0Maybe, I\u00a0don\u2019t\u00a0know,\u00a0you use fertility treatment.\u00a0Maybe you\u00a0have two kids. One gets the flu;\u00a0one breaks a bone. These are not expenses you\u00a0anticipated. And the very core of this pronatalist,\u00a0conservative ideology of supporting families, helping\u00a0it\u00a0become\u00a0easier to raise children,\u00a0becomes a lot harder when you\u00a0don\u2019t\u00a0have affordable health insurance.\u00a0<\/p>\n Kenen:<\/strong>\u00a0I mean, there are some.\u00a0[Louisiana Republican Sen. Bill]\u00a0Cassidy\u2019s plan is a little different. Democrats are still not going to love it. It is money in your pocket of a health savings account or a flexible spending\u00a0account\u00a0\u2014\u00a0I keep reading different details of what it is\u00a0\u2014\u00a0combined with some kind of\u00a0health insurance so that the exposure is not infinite, but\u00a0it\u2019s\u00a0also not\u00a0nothing.\u00a0It\u2019s\u00a0not the same as\u00a0Trump\u2019s plan.\u00a0There\u2019s\u00a0more protection for people in his version. But we\u00a0haven\u2019t\u00a0really seen what his version looks like in detail. I keep reading about all these proposals,\u00a0and I\u00a0can\u2019t\u00a0figure out exactly what they look like because I\u00a0don\u2019t\u00a0think they know yet.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Right, I\u00a0don\u2019t\u00a0think\u00a0they\u2019ve\u00a0been put on paper yet.\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0Well,\u00a0yeah, I asked Cassidy\u2019s office for details earlier this week,\u00a0and they\u00a0didn\u2019t\u00a0respond. I\u00a0don\u2019t\u00a0know if\u00a0they\u2019re\u00a0waiting to see what polls well among colleagues. But I was going to say:\u00a0On\u00a0the politics,\u00a0I\u2019m\u00a0never great\u00a0on\u00a0political analysis because I feel like\u00a0I\u2019m\u00a0always wrong. But I would say\u00a0[the]\u00a0last time Republicans tried to go after ACA\u00a0in 2017, Democrats\u00a0really successfully\u00a0leveraged\u00a0that in the following year. They talked about trying to go after\u00a0protections\u00a0for preexisting conditions.\u00a0And\u00a0you\u2019ve\u00a0already seen, I think, [that]\u00a0the DCCC\u00a0[Democratic Congressional Campaign Committee]\u00a0already put out some ads on the subsidies. So,\u00a0this is going to be a huge, huge point for Democrats.\u00a0They\u2019re\u00a0going to be talking about this nonstop next year.\u00a0So,\u00a0I imagine it would hurt Republicans.\u00a0<\/p>\n I\u2019d\u00a0also add, I think that Democrats sometimes have more to lose on health\u00a0care than Republicans only because health\u00a0care is not a top issue for Republican voters in the way that it is for\u00a0Democratic voters. So,\u00a0sometimes,\u00a0Republicans can make missteps,\u00a0and then their voters are more forgiving of it than\u00a0maybe they\u00a0would be of Democrats.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Although\u00a0we\u2019ll\u00a0see, because as we keep saying,\u00a0there\u2019s\u00a0a lot of Republicans in a lot of these states that have been using these extra subsidies. When they go away,\u00a0they\u2019re\u00a0going to be really ticked off.\u00a0<\/p>\n Kenen:<\/strong>\u00a0Could\u00a0I just say one last thing? And\u00a0we\u2019ve\u00a0said this\u00a0again,\u00a0we\u2019ve\u00a0said this repeatedly, but it is worth bearing,\u00a0repeating\u00a0is:\u00a0Congress usually gives people benefits. Taking away benefits is not really a politically savvy approach. And then,\u00a0yes, Medicaid\u00a0isn\u2019t\u00a0until after the election, after the 2026 elections.\u00a0But there\u2019s going to be repercussions from the Medicaid law that\u00a0[are]\u00a0also going to be felt in the near term in terms of how\u00a0are hospitals\u00a0preparing,\u00a0and responding,\u00a0and cutting back,\u00a0and what\u2019s available in communities,\u00a0and debates in their state legislatures about how they fill budget holes,\u00a0and what services will be cut.\u00a0This is turning into a health\u00a0care year on both the ACA health costs and affordability and the impact of Medicaid that usually helps Democrats. But we are living\u00a0in\u00a0a time of intense short attention spans.\u00a0We\u2019re\u00a0not living in\u00a0\u2026\u00a0the parallels\u00a0don\u2019t\u00a0always apply to the current situation, but\u00a0it\u2019s\u00a0a\u00a0Democratic issue.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yeah. Well,\u00a0continuing on\u00a0my theme of\u00a0maybe Democrats\u00a0didn\u2019t\u00a0really lose the shutdown despite what many of them said,\u00a0I\u2019m\u00a0kind of surprised\u00a0at all the things that did get into the continuing resolution that passed last week and reopened\u00a0the government. Democrats got all the federal workers back pay, which,\u00a0despite being the law,\u00a0was not a given. They got the federal worker firings during the shutdown reversed with a promise of no more\u00a0RIFs [reductions in force]\u00a0until at least the end of the next CR at the end of January. Because the CR also included full-year funding for the Department of Agriculture, they also got SNAP\u00a0[Supplemental Nutrition Assistance Program]\u00a0fully funded through next September.\u00a0<\/p>\n But two other\u00a0really nerdy\u00a0things were tucked into the bill that could turn into a big deal.\u00a0One is the explicit rejection of a proposal to cut in half the budget of the\u00a0Government\u00a0Accountability\u00a0Office, GAO, and preserving the right of the GAO\u2019s head, the\u00a0comptroller\u00a0general,\u00a0to sue the administration for violating the Impoundment Act, which is what protects Congress\u2019\u00a0power of the purse. This is really the fight over the funding bills, right?\u00a0We\u2019ve\u00a0got the Trump administration saying,\u00a0Congress, we\u00a0don\u2019t\u00a0actually care\u00a0what you do in these spending bills.\u00a0We\u2019re\u00a0going to decide how to spend this money.<\/em>\u00a0\u2014\u00a0which is not what the Constitution says.\u00a0<\/p>\n Kenen:<\/strong>\u00a0But the Congress has its\u00a0objective. I mean as the administration\u00a0\u2014\u00a0<\/p>\n Rovner:<\/strong>\u00a0The GAO has,\u00a0and\u00a0they\u2019re\u00a0suing.\u00a0<\/p>\n Kenen:<\/strong>\u00a0Right. But at the end of the day,\u00a0what\u2019s\u00a0happening in the courts is not really changing behavior all that much, so\u00a0it\u2019s\u00a0still\u00a0\u2014\u00a0<\/p>\n Rovner:<\/strong>\u00a0Because it\u00a0hasn\u2019t\u00a0all been resolved yet.\u00a0<\/p>\n Kenen:<\/strong>\u00a0It\u2019s\u00a0a TBD\u00a0[to be\u00a0determined]. I think\u00a0we\u2019ll\u00a0know more after the\u00a0tariffs\u00a0ruling.\u00a0But when they do suffer a defeat in court, they just sort of find another way around.\u00a0Even if they do something, the court says they just find another way of doing what they wanted to\u00a0accomplish.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yes, which we have seen.\u00a0And\u00a0apparently\u00a0they did.\u00a0I saw a story this week that they were trying to put in a provision that would stop what we call\u00a0the pocket\u00a0rescissions. Right now, the administration can say,\u00a0We\u00a0don\u2019t want to spend this money,<\/em>\u00a0and then Congress votes on\u00a0whether or not\u00a0to agree with the administration.\u00a0But if they do it at the end of the fiscal year,\u00a0it\u2019s\u00a0too late. And\u00a0that\u2019s\u00a0called\u00a0a pocket\u00a0rescission. There was some language to stop that,\u00a0which also appears on its face to be illegal. And apparently Russell\u00a0Vought\u00a0of OMB\u00a0[Office of Management and Budget]\u00a0complained,\u00a0and it was taken out of the bill before it was passed. So that fight\u00a0[is]\u00a0going\u00a0to\u00a0still\u00a0continue.\u00a0<\/p>\n Well,\u00a0there\u2019s\u00a0another even more nerdy provision that resets something called the PAYGO\u00a0[pay-as-you-go]\u00a0scorecard to zero. Among other things, this cancels the required cuts to Medicare that\u00a0would\u2019ve\u00a0been the result of the Republicans\u00a0failing to offset\u00a0the cost of the tax cuts in last summer\u2019s\u00a0big\u00a0budget\u00a0bill. You may have heard Democrats referring to these cuts and thought they meant Medicaid,\u00a0thought they were misspeaking.\u00a0They were not.\u00a0There actually was a half-a-billion-dollar cut to Medicare that was in the offing.\u00a0But canceling this kind of cuts both ways because it takes away a talking point for Democrats, right?\u00a0<\/p>\n Kenen:<\/strong>\u00a0Yes, but I\u00a0don\u2019t\u00a0know that that\u00a0one\u2019s\u00a0going to matter so much in\u00a0six, 10, 12 months. Because also,\u00a0we\u2019re\u00a0used to them not\u00a0doing\u00a0the cuts to Medicare that\u00a0they\u2019ve\u00a0said.\u00a0I mean, they walk to the very edge\u00a0of the plank and jump back into the boat\u00a0over and over again\u00a0since 2012 at least, probably before that.\u00a0So\u00a0I\u00a0don\u2019t\u00a0know\u00a0that\u00a0that has\u00a0the staying\u00a0power.\u00a0It\u2019s\u00a0hard. Like the word sequester, unfortunately we understand it, but a lot of people think\u00a0it\u2019s\u00a0a jury. I mean cuts that\u00a0didn\u2019t\u00a0happen\u00a0\u2014\u00a0<\/p>\n Rovner:<\/strong>\u00a0Right, and cuts that are not going to happen.\u00a0We\u2019ll\u00a0see how long it takes the Democrats to wipe the Medicare cuts out of their talking points, which they now\u00a0have to\u00a0do because that was in the bill.\u00a0Well, meanwhile, even with the government back open, the\u00a0chaos\u00a0continues at Robert F. Kennedy Jr.\u2019s\u00a0Department of Health and Human Services, where just this morning\u00a0we\u2019ve\u00a0seen a change to the CDC\u00a0[Centers for Disease Control and Prevention]\u00a0website suggesting that vaccines might cause autism. They do not. And a new large-scale study\u00a0showing\u00a0that fluoride in typical doses\u00a0doesn\u2019t\u00a0lower kids\u2019\u00a0IQs, which is the exact opposite of what RFK\u00a0Jr. has been saying. Paige and Shefali,\u00a0you\u2019re\u00a0following this report on transgender care, which is another sort of big controversial issue over at HHS.\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0Yeah.\u00a0So\u00a0what we saw yesterday was\u00a0basically the\u00a0final release of this report, which was ordered up by Trump via executive order earlier this year. And they had released\u00a0an initial\u00a0draft last spring, but at that time, they\u00a0didn\u2019t\u00a0release the names of the authors on the report, nor did\u00a0it\u00a0have any peer reviewers. And that was the focus of a lot of the criticism of the report\u00a0\u2014\u00a0that there\u00a0wasn\u2019t\u00a0transparency there to see who was\u00a0actually reviewing\u00a0all of\u00a0this evidence around gender-transition care for kids. So,\u00a0we saw the names of the nine authors\u00a0were released\u00a0yesterday,\u00a0as well as about eight peer reviewers. This also, not shockingly, did not engender a lot of wide confidence in the medical community about this report. And the authors of the report all have prior histories of criticizing how gender-transition care is delivered in the U.S. And critics have pointed to that saying:\u00a0Well, the report\u2019s not legitimate because\u00a0basically the\u00a0people were handpicked by the administration to deliver a particular conclusion.<\/em>\u00a0<\/p>\n And\u00a0so\u00a0I\u2019ve\u00a0been talking to some of the authors. They are of course defensive. They say,\u00a0Look\u00a0at the research.\u00a0Look at the report.\u00a0<\/em>The report does\u00a0skew\u00a0very critical\u00a0of transition care and recommends counseling first, which is something that some of the leading medical organizations are pushing back against. So,\u00a0I\u00a0don\u2019t\u00a0know where all this is going to go. I think the debate\u00a0[is]\u00a0going to continue, but certainly\u00a0we\u2019re\u00a0going to see the administration use this report to try to\u00a0undergird\u00a0its arguments for\u00a0a\u00a0dramatic crackdown on transition care.\u00a0They\u2019re\u00a0actually working\u00a0on two rules at CMS\u00a0[Centers for Medicare & Medicaid Services]\u00a0right now which would penalize hospitals for providing transition care for kids. Those rules are being reviewed I think by the White House right now, but\u00a0we\u2019re\u00a0probably going\u00a0to see those\u00a0finalized\u00a0sometime next year.\u00a0<\/p>\n Luthra:<\/strong>\u00a0I think some really important context for us to consider here\u00a0\u2014\u00a0in this conversation as well as what the actual reality of health\u00a0care looks like for trans youth\u00a0\u2014\u00a0and in particular, the thing that really stands out to me as we look at this report and look at these criticisms that these authors are levying,\u00a0is that already, for young people who are getting gender-affirming care, it\u2019s a very involved process. There\u00a0aren\u2019t\u00a0a lot of providers who offer this to begin with. There is a lot of counseling. The idea that young people are getting these gender-affirming surgeries at\u00a0a young age\u00a0without any sort of long-thought,\u00a0long conversation\u00a0just\u00a0isn\u2019t\u00a0really borne out by evidence. There is a lot of conversation, a\u00a0lot of counseling. A lot of youth\u00a0start\u00a0with things that are reversible. You start with\u00a0maybe something\u00a0that\u00a0doesn\u2019t\u00a0have that same level of permanence before ensuring that this is something that people truly do want. And I think\u00a0that\u2019s\u00a0really important.\u00a0<\/p>\n The other thing that really sits with me in this conversation\u00a0\u2014\u00a0which I think this is a conversation that has been really built up by a lot of social conservatives who are looking for a new target after they sort of lost the war on gay marriage\u00a0\u2014\u00a0is that young people are sort of a starting point. And\u00a0we\u2019ve\u00a0already\u00a0seen a lot of efforts in some states to expand restrictions on gender-affirming care\u00a0\u2014\u00a0not only for young people, but for people of all ages who are trans. It reminds me a lot,\u00a0actually,\u00a0of\u00a0the conversation around abortion,\u00a0where you began with restrictions for young people as a pathway to restricting it writ large.\u00a0And I think we\u00a0have to\u00a0be\u00a0really aware\u00a0of that context when we look at how this political and policy fight unfolds.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yeah,\u00a0there\u2019s\u00a0also a lot less of this care\u00a0you\u2019re\u00a0saying. It is hard to\u00a0get.\u00a0There\u2019s\u00a0less available than there was at the start of the year.\u00a0We\u2019ve\u00a0seen so many of these universities and hospitals knuckle under and say,\u00a0We\u00a0just\u00a0don\u2019t\u00a0want to be part of this because\u00a0they\u2019re\u00a0threatening to take away\u00a0all of\u00a0our funding.<\/em>\u00a0There\u2019s\u00a0a new study in JAMA Internal Medicine this week that found that HHS cuts from earlier this year disrupted more than 400 clinical trials,\u00a0and treatment for more than 74,000 patients who were\u00a0participating\u00a0in those trials. Most impacted, according to the report, were trials on infectious diseases and prevention. But a second study chronicled the deep cuts to gender-affirming care. So,\u00a0it\u2019s\u00a0not even how\u00a0it\u2019s\u00a0being\u00a0delivered,\u00a0it\u2019s\u00a0if<\/em>\u00a0it\u2019s\u00a0being delivered at this point, right?\u00a0<\/p>\n Luthra:<\/strong>\u00a0The people who are getting this health\u00a0care have gone through a lot of hoops to get this care already. They have shown a real\u00a0\u2026\u00a0desire is the wrong word. They have worked\u00a0very, very hard\u00a0to get here in a way that you\u00a0don\u2019t\u00a0do if this\u00a0isn\u2019t\u00a0something you have thought about a lot.\u00a0<\/p>\n Rovner:<\/strong>\u00a0It\u2019s\u00a0not like quitting smoking.\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0But I also add, this\u00a0isn\u2019t\u00a0a conversation\u00a0that\u2019s\u00a0only happening in the U.S.\u00a0This is happening around the world. You have seen a huge surge of young people seeking this care.\u00a0So\u00a0it\u2019s\u00a0kind of a\u00a0relatively new\u00a0thing. And in a way, just in terms of the number of\u00a0people, and\u00a0you\u2019ve\u00a0seen. \u2026\u00a0I think New Zealand\u00a0actually this\u00a0week announced that\u00a0they\u2019re\u00a0putting new restrictions on puberty blockers for young people.\u00a0You\u2019ve\u00a0also seen similar things in the U.K.\u00a0[United Kingdom]\u00a0and the Netherlands. And\u00a0they\u2019ve\u00a0also conducted reviews, just raising questions around how much evidence we have around the long-term benefits or harms of giving these treatments to kids.\u00a0So\u00a0I think\u00a0it\u2019s\u00a0an important conversation for researchers to\u00a0be having. And I think\u00a0it\u2019s\u00a0unfortunate\u00a0it\u2019s\u00a0gotten so politicized,\u00a0because this is,\u00a0to Shefali\u2019s point,\u00a0really important\u00a0for a lot of children in the U.S.\u00a0and around the world.\u00a0And yeah, it\u2019s\u00a0really important\u00a0for researchers to have a\u00a0really clear\u00a0picture of the best way to help them.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yeah, I was going to say this is one of those things\u00a0that\u2019s\u00a0both a culture war issue,\u00a0and a legitimate medical scientific issue that\u00a0we\u2019re\u00a0looking at.\u00a0\u00a0<\/p>\n Well, meanwhile,\u00a0it\u2019s\u00a0not just policy\u00a0that\u2019s\u00a0a little chaotic at HHS. According to\u00a0The Wall Street Journal, the secretary\u00a0reportedly considered\u00a0sidelining FDA\u00a0[Food and Drug Administration]\u00a0Commissioner Marty Makary because of his inability to control infighting between some of his division directors. Yet it feels like\u00a0FDA\u00a0is\u00a0kind of the\u00a0least of Kennedy\u2019s worries right now. Also ongoing\u00a0are\u00a0fights between supporters of MAGA, the Make America Great Again movement,\u00a0and MAHA, the Make America Healthy Again movement,\u00a0over who should\u00a0be in charge of\u00a0health policy. Is this just usual\u00a0infighting,\u00a0or is this sort of new and different and\u00a0[at]\u00a0a more significant level than we\u00a0often\u00a0see?\u00a0<\/p>\n Kenen:<\/strong>\u00a0I\u2019m not sure we know yet,\u00a0because some of this stuff is boiling up\u00a0pretty quickly.\u00a0But\u00a0we\u2019re\u00a0seeing all sorts of splits and fractures on the Republican side that we have not been accustomed to seeing. Trump is\u00a0very good\u00a0at unifying his party,\u00a0and papering over things,\u00a0and changing the subject.\u00a0He\u2019s\u00a0a very, very gifted controller of narrative.\u00a0And the fact that\u00a0we\u2019re\u00a0seeing policy splits as well as the\u00a0[Jeffrey]\u00a0Epstein scandal,\u00a0and all sorts of other things,\u00a0it\u2019s\u00a0not one crack.\u00a0There\u2019s\u00a0a bunch. And crack might be too\u00a0strong\u00a0a word\u00a0\u2014\u00a0we\u00a0don\u2019t\u00a0know yet\u00a0\u2014\u00a0but\u00a0we\u2019re\u00a0seeing more dissent,\u00a0and more disagreement bubbling over in public than we had before.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yes, and\u00a0that\u2019s\u00a0what\u2019s\u00a0so unusual to me.\u00a0Have these people had long knives out for each other?\u00a0Absolutely. Have we seen big front-page stories about it? Not so much.\u00a0<\/p>\n Kenen:<\/strong>\u00a0And\u00a0it\u2019s\u00a0heightened since the New Jersey and Virginia races.\u00a0It\u2019s\u00a0more blame-gaming going around.\u00a0So\u00a0I think\u00a0we\u2019re\u00a0seeing a slightly different internal landscape among Republicans, as we just said,\u00a0it\u2019s\u00a0apparent\u00a0how much these health\u00a0care versus public health versus vaccine versus MAHA versus MAGA, these\u00a0\u2026\u00a0how much they splinter and stay splintered.\u00a0It\u2019s\u00a0interesting to watch right now. I mean,\u00a0Kennedy\u00a0hasn\u2019t\u00a0been that engaged on the health policy side, the insurance fight, the HSAs, FSAs, subsidies.\u00a0That\u2019s\u00a0not where his public energy is.\u00a0<\/p>\n Rovner:<\/strong>\u00a0He\u2019s\u00a0left that to Dr.\u00a0[Mehmet]\u00a0Oz mostly.\u00a0<\/p>\n Kenen:<\/strong>\u00a0Right. And we know\u00a0what\u2019s\u00a0important to him.\u00a0There\u2019s\u00a0a long list\u00a0of changes he wants to make on that side. So, I think\u00a0it\u2019s\u00a0interesting. I think\u00a0it\u2019s\u00a0significant. I\u00a0don\u2019t\u00a0know what\u00a0it\u2019s\u00a0going to look like in a month.\u00a0<\/p>\n Rovner:<\/strong>\u00a0OK.\u00a0We\u2019re\u00a0going to take a quick break,\u00a0and we will\u00a0be right\u00a0back.\u00a0<\/p>\n OK.\u00a0We\u2019re\u00a0back. Well, there is also news,\u00a0finally,\u00a0this week on the reproductive health front,\u00a0as you tried to jump the gun, Paige. Circling back for a minute to the impending vote on extending the enhanced ACA subsidies, abortion turns out to be a big obstacle to any potential compromise, even if there was one to be had. This\u00a0shouldn\u2019t\u00a0really be surprising. Abortion very nearly scuttled the passage of the ACA itself in 2010\u00a0\u2014\u00a0<\/p>\n Luthra:<\/strong>\u00a0At the very last minute.\u00a0<\/p>\n Rovner:<\/strong>\u00a0At the very last minute. And anti-abortion forces still think the law is too lenient, even though\u00a0it\u2019s\u00a0a lot more restrictive than abortion-rights backers had wanted and fought for. Shefali, are Republicans really going to refuse to stop premium increases for voters just to please the anti-abortion movement?\u00a0<\/p>\n Luthra:<\/strong>\u00a0I\u00a0don\u2019t\u00a0see\u00a0why not. It seems like this is\u00a0\u2026 I mean, really,\u00a0though,\u00a0the anti-abortion movement in some ways took a\u00a0pretty big\u00a0loss getting Trump as the Republican president. This is someone who does not really want to capitalize on the post-ops\u00a0momentum with a national ban. And\u00a0so\u00a0they\u2019re\u00a0looking where they\u00a0can to\u00a0try and restrict abortion through other means\u00a0\u2014\u00a0whether that meant the Planned Parenthood defunding, whether that means trying to get this mifepristone reviewed,\u00a0or if it means trying to enact more restrictions through ACA subsidies. It really\u00a0seems like\u00a0kind of\u00a0a no-brainer. If you\u00a0can\u2019t\u00a0get this win for\u00a0a very important\u00a0constituency from the president, you do what you can\u00a0everywhere\u00a0else to try and get\u00a0it,\u00a0or\u00a0get at least what you can.\u00a0<\/p>\n Rovner:<\/strong>\u00a0OK. Paige, now you get to say what you wanted to say before.\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0Well, no,\u00a0I guess I\u00a0was just going to say again,\u00a0I\u2019ve\u00a0just been thinking a lot about 2017 and how health reform never seems to go forward. But\u00a0yeah, this is a perennial issue.\u00a0It\u2019s\u00a0all about the\u00a0Hyde\u00a0[Amendment]\u00a0language and anti-abortion folks,\u00a0and Republicans have always been very resentful of how the debate about the ACA went about. And they are upset because they think these plans are that taxpayer dollars are still going to abortions,\u00a0et cetera, et cetera.\u00a0And actually, I\u00a0was thinking with this HSA idea of rerouting the subsidies to the HSAs, the problem would\u00a0actually be\u00a0even more pronounced,\u00a0because they\u2019re going to demand that you attach then abortion restrictions to money that people have in their own accounts that they\u2019re supposed to be using for health\u00a0care. And that just seems like even more of a no-go with Democrats. I think all of us knew this was a big obstacle, but it takes a little bit of time for people\u00a0on\u00a0[Capitol]\u00a0Hill to figure this out, but I think\u00a0it\u2019s\u00a0becoming\u00a0more and more\u00a0clear that this is just a\u00a0really massive\u00a0barrier.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yeah, it is. All\u00a0right,\u00a0well the abortion fight also continues in the states. South Carolina lawmakers this week held a hearing on what\u00a0would\u2019ve\u00a0been the strictest abortion ban in the country, allowing judges to send women who have abortions to prison,\u00a0and potentially restricting IVF\u00a0[in vitro fertilization]\u00a0and some forms of birth control.\u00a0Apparently,\u00a0that\u00a0bill went a little too far, even for some Republicans on the subcommittee. The bill\u00a0failed to\u00a0advance, at least for now. Are we likely to see more laws like this,\u00a0though,\u00a0as states try to top one another\u00a0in\u00a0pleasing what the anti-abortion forces want?\u00a0<\/p>\n Luthra:<\/strong>\u00a0I think we will. This is a\u00a0really long-standing\u00a0and deep debate in the state-based anti-abortion movement,\u00a0and in particular\u00a0the debates over contraception, the debates over IVF,\u00a0and especially around whether you send someone who gets an abortion to prison, whether\u00a0they\u2019re\u00a0held criminally liable. And there is a very extreme movement;\u00a0they call themselves abortion abolitionists. They\u00a0are introducing\u00a0bills and growing numbers every year,\u00a0trying to\u00a0build up\u00a0support. Even some of the pretty conservative abortion opponents say,\u00a0Oh, those people are too extreme for me.<\/em>\u00a0But\u00a0they\u2019re\u00a0gaining influence. And I see this as a conversation and a debate that the anti-abortion movement only continues to have, especially as this is something that progresses on the state level and not necessarily the federal one.\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0I do wonder,\u00a0though,\u00a0how much more room there is for state bans, because you saw this huge surge in red states placing bans after\u00a0Dobbs<\/em>\u00a0[Dobbs v. Jackson Women\u2019s Health Organization<\/em>].\u00a0At this point, I think around 17 or so states have\u00a0almost-complete\u00a0bans on abortion.\u00a0So\u00a0in a way,\u00a0I think\u00a0there\u2019s\u00a0been a lot of work done there. And I think the opportunity that the anti-abortion folks see is at the federal level, but of course they\u2019re running into top appointees\u00a0\u2014\u00a0Kennedy, some of the others at HHS,\u00a0who,\u00a0for them,\u00a0this is really not a priority\u00a0\u2014\u00a0and it doesn\u2019t sound like anti-abortion folks would love to see them roll back access to mifepristone, for example.\u00a0I\u2019m\u00a0not convinced\u00a0that\u2019s\u00a0going to happen anytime soon because the folks pulling the levers there\u00a0aren\u2019t\u00a0necessarily in the camp.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yeah,\u00a0apparently one\u00a0of the reasons that people\u00a0aren\u2019t\u00a0angry with Marty Makary at FDA is because he appears to be\u00a0slow-walking\u00a0this mifepristone study,\u00a0and he approved, even though\u00a0he had to, another generic of the medication. So,\u00a0I know that that\u2019s also part of this.\u00a0<\/p>\n Luthra:<\/strong>\u00a0If I can add one more thing, Julie?\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yes, please.\u00a0<\/p>\n Luthra:<\/strong>\u00a0Frankly, a\u00a0really good\u00a0litmus test\u00a0for where states are heading is coming in only a few weeks when Texas\u2019\u00a0new abortion law takes effect.\u00a0And this is one of the most ambitious efforts to stop telehealth and shield\u00a0law\u00a0provision of abortion. And this is an area where state-based abortion opponents are very\u00a0frustrated,\u00a0because\u00a0they see it as breaking or fundamentally incapacitating their abortion bans when people can still get medication through the mail from doctors who have not been successfully prosecuted for doing so. And so,\u00a0when this law takes effect, it enables civil lawsuits against people who make medication abortion available in Texas. I think we will see:\u00a0Are there civil suits filed by abortion opponents, for\u00a0instance.\u00a0Is there any really concerted effort to use this new tool to stop telehealth? And if so, does that spread to other states? Especially since Texas has for so long been a real pioneer in abortion restrictions and making\u00a0it\u00a0even harder to get.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Yeah, where Texas goes, so\u00a0go\u00a0the rest of the red states.\u00a0<\/p>\n All right, that is all the time we have for the news this week. Now we will play my interview with Republican health expert Avik Roy, and then we will come back and do our extra credits.\u00a0<\/p>\n I am so pleased to\u00a0welcome to\u00a0the podcast Avik Roy here in person in our studio at KFF. Avik is co-founder and\u00a0chairman\u00a0of the Foundation for Research on Equal Opportunity, which studies and recommends social policies for the half of the population that earns less than the U.S.\u00a0median. But\u00a0he\u2019s\u00a0also a longtime health policy wonk and health adviser to Republicans,\u00a0including several Republican presidential candidates over the years. And full\u00a0disclosure,\u00a0he is, like me, a fellow Michigan Wolverines fan.\u00a0<\/p>\n Avik Roy:<\/strong>\u00a0Go,\u00a0Blue.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Avik, welcome to\u00a0\u201cWhat the Health?\u201d\u00a0<\/p>\n Roy:<\/strong>\u00a0Great to see you, Julie.\u00a0<\/p>\n Rovner:<\/strong>\u00a0So,\u00a0how did you come to health policy? It was a bit of a\u00a0winding\u00a0road, wasn\u2019t it?\u00a0<\/p>\n Roy:<\/strong>\u00a0Yeah, I\u00a0kind of fell\u00a0into it.\u00a0I was working as a health\u00a0care investor,\u00a0actually,\u00a0at\u00a0Bain Capital\u00a0and\u00a0a couple\u00a0of\u00a0other places like that,\u00a0as a health\u00a0care investor.\u00a0In 2008,\u00a0[Barack]\u00a0Obama gets\u00a0elected\u00a0and starts to talk about what we now call the Affordable Care Act,\u00a0or Obamacare. And I\u00a0wasn\u2019t\u00a0reading anything I agreed with. At that time, you had Ezra Klein,\u00a0then at\u00a0The Washington Post, and you had Jonathan Cohn at\u00a0The New Republic. You had that group of young bloggers who are writing,\u00a0Hey,\u00a0there\u2019s\u00a0this brilliant MIT economist named Jonathan Gruber,\u00a0and\u00a0he\u2019s\u00a0got it all figured out,\u00a0and\u00a0everything\u2019s\u00a0going to work great,\u00a0and premiums are going to go down.<\/em>\u00a0And Obama himself promised that premiums for the average family of four would decline by $2,500 per year.\u00a0That\u2019s\u00a0what he campaigned\u00a0on\u00a0in 2008. Then on the conservative side, you had a lot of people writing things like,\u00a0It\u2019s\u00a0big\u00a0government.\u00a0It\u2019s\u00a0unconstitutional.\u00a0It\u2019s\u00a0welfare.<\/em>\u00a0<\/p>\n And I found these arguments\u00a0kind of like\u00a0empty calories,\u00a0because for the average American\u00a0who\u2019s\u00a0struggling to afford health insurance and health\u00a0care, I just\u00a0don\u2019t\u00a0see how that person is going to respond to that kind of argument.\u00a0They\u2019re\u00a0going to be like,\u00a0Look, if one side is telling me\u00a0they\u2019re\u00a0going to reduce my premiums by $2,500 per family per year, and the other side is just saying, ignore this all because\u00a0it\u2019s\u00a0big government, which side is the average\u00a0person\u00a0going to choose?<\/em>\u00a0They\u2019re\u00a0going to choose a side\u00a0that\u2019s\u00a0going to try to reduce their health\u00a0care bills. And my point of view was not aligned with either of those positions. My point of view was actually:\u00a0Health\u00a0care bills are going to continue to increase,\u00a0and the design of the ACA has\u00a0a number of\u00a0flaws that are not being called out because the conservative critics just\u00a0weren\u2019t\u00a0digging into the technical design\u00a0\u2014\u00a0the architecture of the bill.\u00a0And even though\u00a0I\u2019m\u00a0not as eminent as Jonathan Gruber, I did go to MIT. And\u00a0so\u00a0I\u00a0maybe\u00a0felt a little more willing to engage in that debate.\u00a0<\/p>\n Rovner:<\/strong>\u00a0And\u00a0you\u2019re\u00a0a doctor.\u00a0<\/p>\n Roy:<\/strong>\u00a0Well, I went to med school.\u00a0I never practiced,\u00a0don\u2019t\u00a0have a license.\u00a0<\/p>\n Rovner:<\/strong>\u00a0But you have,\u00a0at least,\u00a0the medical\u00a0education.\u00a0So\u00a0you have a good\u00a0bit of background\u00a0in this. I want to think broadly. Every other developed country has some sort of national health insurance scheme. Most of them are hybrids of public and\u00a0private. Some of them\u00a0more\u00a0public;\u00a0some of them\u00a0more\u00a0private. Why hasn\u2019t the U.S.\u00a0been able to solve this problem that every other developed country has?\u00a0<\/p>\n Roy:<\/strong>\u00a0We\u00a0actually do\u00a0a lot of work on this at the\u00a0Foundation for\u00a0Research on\u00a0Equal\u00a0Opportunity.\u00a0We have a whole annual research product we put out called the World Index of Healthcare Innovation, where we compare 32 countries around the world with the highest GDP\u00a0[gross domestic product]\u00a0per capita that have a population over 5 million on quality, choice, science and technology, and fiscal sustainability. So,\u00a0a number of\u00a0other people\u00a0do\u00a0these kinds of comparisons, but our\u00a0study is\u00a0different for two reasons. One, we\u00a0don\u2019t\u00a0just look at OECD\u00a0[Organization for Economic Co-operation and Development]\u00a0countries, which is typically where most academics get their data. We look at countries that are outside the OECD, particularly in Asia. And we also again score countries not merely on health outcomes and equity-type measures, but we also look at things like fiscal sustainability, which we think\u00a0matters for\u00a0long-term equity,\u00a0and science and technology. One of the defenses of the American system that you always hear is,\u00a0Well, yes, our system is so expensive, but\u00a0we\u2019re\u00a0also the innovation center of the world,\u00a0and you\u00a0can\u2019t\u00a0have one without the other.<\/em>\u00a0<\/p>\n So,\u00a0one thing that we wanted to study was:\u00a0Is that\u00a0really true?\u00a0Can you have innovation at a U.S.-like level but with a universal system that covers everybody and has\u00a0good quality? And the system that has ranked\u00a0No. 1\u00a0in our study every year is Switzerland. The reason\u00a0that\u2019s\u00a0really interesting\u00a0is because\u00a0there\u2019s\u00a0a misconception,\u00a0both on the left\u00a0and\u00a0the right,\u00a0that to achieve universal health insurance you\u00a0have to\u00a0have a single-payer system.\u00a0And that\u2019s not actually true.\u00a0There are plenty of countries\u00a0\u2014\u00a0they\u00a0are a minority of the industrialized countries, but\u00a0it\u2019s\u00a0a robust and significant minority\u00a0\u2014\u00a0that have achieved universal coverage using private insurance, not necessarily a single-payer,\u00a0government-run insurer. And Switzerland is, in our view, the best example of that because Switzerland is a place where\u00a0there\u2019s\u00a0an innovative pharmaceutical and biotech,\u00a0and med devices ecosystem. They have universal coverage.\u00a0It\u2019s\u00a0basically like\u00a0Medicare Advantage for all,\u00a0or Obamacare for all.\u00a0It\u2019s\u00a0a universal individual market where the market is regulated and subsidized, but it works.\u00a0<\/p>\n Rovner:<\/strong>\u00a0I would say big subsidies.\u00a0I\u2019ve\u00a0been to Switzerland.\u00a0I\u2019ve\u00a0studied the Swiss health\u00a0care system.\u00a0<\/p>\n Roy:<\/strong>\u00a0Big subsidies.\u00a0It depends on your\u00a0vantage point.\u00a0Relative\u00a0to the American system, the subsidies are\u00a0actually quite\u00a0low.\u00a0So\u00a0what Switzerland spends subsidizing health\u00a0care is about 45% of what the U.S.\u00a0spends per capita subsidizing health\u00a0care. We\u00a0actually subsidize\u00a0health\u00a0care per capita more than any other country in the\u00a0world,\u00a0because\u00a0the cost of health\u00a0care is so high in America that the cost of subsidizing health\u00a0care\u00a0is\u00a0so high.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Which was going to be my second point about Switzerland\u00a0is\u00a0that\u00a0it\u2019s\u00a0way more regulated than a lot of Republicans think.\u00a0<\/p>\n Roy:<\/strong>\u00a0Well,\u00a0it\u2019s\u00a0about as regulated as Medicare Advantage,\u00a0or the ACA plans in terms of the insurance plan to sign. There are other things\u00a0\u2014\u00a0and we\u00a0don\u2019t\u00a0have to spend\u00a0all of\u00a0our time on Switzerland here\u00a0\u2014\u00a0but you ask the question,\u00a0it\u2019s\u00a0like,\u00a0Why\u00a0can\u2019t we do this in America?<\/em>\u00a0That was your original question,\u00a0and there\u2019s\u00a0a number of\u00a0reasons for that.\u00a0One is path dependence. With any health\u00a0care system, once\u00a0you\u2019ve\u00a0established\u00a0it,\u00a0it\u2019s\u00a0hard to change. The one thing\u00a0I\u2019ll\u00a0say that we did in the mid-20th century that really put us on this path was when we\u00a0excluded from\u00a0taxation\u00a0employer-sponsored\u00a0insurance,\u00a0because in World War II there were wage and price controls. Employers figured out how to get around that by offering employer-sponsored insurance that\u00a0wasn\u2019t\u00a0regulated by wage and price controls. And then after the war,\u00a0[Dwight D.]\u00a0Eisenhower said,\u00a0Yeah,\u00a0let\u2019s\u00a0not tax those insurance policies because they\u00a0seem to be\u00a0important for people.<\/em>\u00a0<\/p>\n And\u00a0it was\u00a0kind of an\u00a0offhanded\u00a0decision. No one really knew that that was going to be this\u00a0big thing. But sure enough\u00a0\u2014\u00a080 years later,\u00a0or 70 years later\u00a0\u2014\u00a0here we are. And I would argue\u00a0that\u2019s\u00a0the biggest\u00a0driver of health\u00a0care inflation, because we\u00a0don\u2019t\u00a0merely have third-party payment for health\u00a0care. Every country has third-party\u00a0payment\u00a0for health\u00a0care. But we have third-party payment of third-party payment of health\u00a0care. We have ninth-party payment of health\u00a0care basically. And no wonder that no one has any sense of why everything is so expensive. But\u00a0that\u2019s\u00a0the core driver.\u00a0And unfortunately,\u00a0Medicare,\u00a0in particular,\u00a0built\u00a0on that system.\u00a0When the Medicare law was passed in 1965, a key element of Medicare was to build upon and drive the benefits based on the traditional Blue Cross employer-based plan, which had by that point already ballooned into something resembling what we have now.\u00a0<\/p>\n Rovner:<\/strong>\u00a0So why has health\u00a0care been such a low priority for Republicans? I always hear,\u00a0Well, Republicans\u00a0don\u2019t\u00a0really work on this because\u00a0it\u2019s\u00a0not important to their voters.<\/em>\u00a0That\u00a0can\u2019t\u00a0possibly be\u00a0true anymore.\u00a0<\/p>\n Roy:<\/strong>\u00a0I think everything you said is\u00a0just right. I think that historically,\u00a0Republicans\u00a0didn\u2019t\u00a0feel that it was relevant to their voters. And their voters\u00a0weren\u2019t\u00a0really pushing for it because their voters were\u00a0\u2014\u00a0relative\u00a0to the median constituent\u00a0\u2014\u00a0perhaps more\u00a0likely to be employed,\u00a0or more likely to be on Medicare\u00a0\u2014\u00a0and therefore\u00a0didn\u2019t\u00a0feel like they had to worry about affordability. But affordability, as everybody at KFF knows, and the audience that listens to your program knows, affordability\u00a0is a big deal\u00a0for everyone. Premiums in the employer-sponsored market have gone up, and people\u00a0don\u2019t\u00a0necessarily notice that.\u00a0But they notice that their paychecks have been flat. They notice their deductibles going up,\u00a0and their copays going up,\u00a0and\u00a0that\u2019s\u00a0been a big problem both in the ACA markets,\u00a0and the employer market.\u00a0<\/p>\n But affordability\u00a0is a big deal. And now that the Trump GOP has become more of a working\u00a0man and woman\u2019s party\u00a0\u2014 and you see it in all the exit polls that if you actually look at who\u2019s voting for Democrats and who\u2019s voting\u00a0for\u00a0Republicans in presidential election years\u00a0\u2014\u00a0the Republican electorate is now a bit more lower-income than the Democratic constituency, which has a lot more of those college grads,\u00a0and grad school grads. I think\u00a0you\u2019re\u00a0starting to see more of that\u00a0populist\u00a0concern about the affordability of health\u00a0care, but\u00a0there\u2019s\u00a0still an enormous amount of intellectual catch-up to get there. And I think because of this experience of studying the international health\u00a0care world,\u00a0I\u2019ve\u00a0been much more optimistic about the ability to achieve universal coverage in a way\u00a0that\u2019s\u00a0friendly to free marketeers, people who believe in private-sector competition.\u00a0<\/p>\n Whereas I think the traditional Republican view, which you\u00a0kind of alluded\u00a0to earlier\u00a0\u2014\u00a0and I ran into this a lot in the 2017 repeal-and-replace debate\u00a0\u2014\u00a0was\u00a0it\u2019s\u00a0not the federal government\u2019s job to ensure that everybody has affordable health insurance.\u00a0That\u2019s\u00a0what I heard from a lot of the kind of old-line Republicans and Republican staffers in the 2010s.\u00a0It\u2019s\u00a0not the federal government\u2019s job to guarantee affordable health insurance for people.\u00a0That\u00a0should be up to ordinary people to make enough money to afford health insurance. And I disagree with that very strongly. And the reason I disagree with that very strongly is because it was the federal government that screwed it up in the first place. It was the tax exclusion for employer-sponsored insurance, and then some of the things around the design of Medicare that drive all the health\u00a0care inflation that\u00a0we\u2019ve\u00a0seen over the last 80 years.\u00a0<\/p>\n So\u00a0the federal government created the mess, and it is the federal government\u2019s job to clean up the mess. And I guess you could say a big purpose of my work is to try to convince more Republicans to agree with me on that.\u00a0<\/p>\n Rovner:<\/strong>\u00a0So why has it been so hard for Republicans to come together on anything? The Democrats have big divisions,\u00a0too,\u00a0on health\u00a0care. They have\u00a0a big chunk\u00a0of Democrats who would like\u00a0\u201cMedicare for\u00a0All,\u201d\u00a0and another chunk of Democrats who would like to build on the existing system. Republicans\u00a0presumably have\u00a0the same kinds of divisions,\u00a0just in the other direction, and yet we almost never see Republican proposals,\u00a0and we do see\u00a0Democratic proposals.\u00a0<\/p>\n Roy:<\/strong>\u00a0Well, I will quibble with you a little bit, Julie, in that there are Republican proposals. They\u00a0don\u2019t\u00a0always get the same amount of media coverage that the Democratic proposals get. There is a bill\u00a0that\u2019s\u00a0been introduced in both the House and the Senate,\u00a0based on our work at FREOPP,\u00a0called the Fair Care\u00a0Act, which would achieve voluntary universal coverage. It\u00a0wouldn\u2019t\u00a0force anyone to buy coverage, but everyone who wants to buy health insurance would be guaranteed to have an affordable\u00a0option.\u00a0It would reduce the deficit, increase coverage by about\u00a09\u00a0to 10 million,\u00a0and also\u00a0reduce federal spending.\u00a0It would reduce taxes,\u00a0and reduce federal spending,\u00a0because it would reduce the underlying cost of health\u00a0care.\u00a0<\/p>\n Rovner:<\/strong>\u00a0How?\u00a0<\/p>\n Roy:<\/strong>\u00a0By,\u00a0in particular,\u00a0tackling\u00a0the power of hospital monopolies,\u00a0and being more aggressive about high drug prices.\u00a0And it would also\u00a0means-test the subsidies. And by means-testing,\u00a0I\u00a0don\u2019t\u00a0just mean means-testing Medicare, which is often what people talk about, but also means-testing the employer tax break for health insurance, for example, and really having\u00a0\u2014\u00a0<\/p>\n Rovner:<\/strong>\u00a0So more like Switzerland.\u00a0<\/p>\n Roy:<\/strong>\u00a0Exactly.\u00a0So\u00a0all these random digressions that\u00a0I\u2019ve\u00a0been coming\u00a0\u2026\u00a0there is\u00a0actually a\u00a0coherent idea here that\u00a0I\u2019m\u00a0trying to get to, and I thank you for reminding me on that.\u00a0<\/p>\n Rovner:<\/strong>\u00a0Well,\u00a0we\u2019re\u00a0back in\u00a0the thick\u00a0of it. Avik Roy,\u00a0hope\u00a0we can have you back again.\u00a0<\/p>\n Roy:<\/strong>\u00a0Thanks, Julie.\u00a0I\u2019d\u00a0love it.\u00a0<\/p>\n Rovner:<\/strong>\u00a0OK.\u00a0We\u2019re\u00a0back.\u00a0It\u2019s\u00a0time for our\u00a0extra-credit\u00a0segment.\u00a0That\u2019s\u00a0where we each recognize\u00a0a\u00a0story we read this\u00a0week\u00a0we think you should read,\u00a0too.\u00a0Don\u2019t\u00a0worry if you miss it. We\u00a0will\u00a0put the links in our show notes on your phone or other mobile device. Paige, why don\u2019t you\u00a0go\u00a0first this week?\u00a0<\/p>\n Winfield Cunningham:<\/strong>\u00a0Sure.\u00a0Yeah. Well, I was really struck by this story in\u00a0The Wall Street Journal called\u00a0\u201c
\n\t\t\t\t@jrovner\t\t\t<\/a><\/p>\n
\n\t\t\t\t@julierovner.bsky.social\t\t\t<\/a><\/p>\n
\n\t\t\t\tRead Julie’s stories.\t\t\t<\/a><\/p>\n\n\t\tPanelists\t<\/h3>\n
<\/p>\n
\n\tThe Washington Post<\/p>\n
\n\t\t\t\t@pw_cunningham\t\t\t<\/a><\/p>\n
\n\t\t\t\tRead Paige’s stories.\t\t\t<\/a><\/p>\n<\/p>\n
\n\tJohns Hopkins University and Politico<\/p>\n
\n\t\t\t\t@JoanneKenen\t\t\t<\/a><\/p>\n
\n\t\t\t\t@joannekenen.bsky.social\t\t\t<\/a><\/p>\n
\n\t\t\t\tRead Joanne’s bio.\t\t\t<\/a><\/p>\n<\/p>\n
\n\tThe 19th<\/p>\n
\n\t\t\t\t@shefali.bsky.social\t\t\t<\/a><\/p>\n
\n\t\t\t\tRead Shefali’s stories.\t\t\t<\/a><\/p>\n\n
\n